The Prognostic Value of Previous Coronary Stent Implantation in Patients Undergoing Myocardial Revascularization Surgery.

BACKGROUND: Currently, studies are underway to determine whether coronary stent implantation with percutaneous transluminal coronary angioplasty before a coronary artery bypass graft (CABG) influences the prognosis of surgery. This study aimed to assess the need for future revascularisation or all-cause mortality as a composite endpoint after CABG surgery among patients with previous stent implantation. METHODS: A retrospective, non-randomised study was performed on 721 patients who underwent CABGin our centre between 2012 and 2017. This single-centre study compared two groups: 1) the previous stent group, patients with previous stent implantation (n=144), and 2) the non-previous stent group, patients without previous stent implantation (n=577). RESULTS: After a median follow-up of 36 months, the previous stent group presented a decreased combined event-free survival at 1, 3 and 5 years compared with the non-previous stent group (67.4, 43.5 and 23.0% vs. 91.0, 80.3 and 63.0%, respectively; p<0.01). There was also higher mortality in the previous stent group than in the non-previous stent group (96.1, 90.5 and 79.4 vs. 91.9, 75.9 and 51.0, respectively; p=0.01). The multivariable analysis of demographics, baseline comorbidity and surgical data showed previous stent implantation as an independent predictor of the composite endpoint (Hazard Ratio=3.00 and 95% confident interval=2.09-4.32; p<0.01). CONCLUSION: Patients with percutaneous coronary intervention before CABG present higher comorbidities and clinical events during follow-up than those who do not undergo stenting.

A new approach to the treatment of advanced heart failure: a case report.

BACKGROUND: Autonomic imbalance characterized by sympathetic predominance and decreased parasympathetic transmission is a classic feature of heart failure (HF) with reduced left ventricular ejection fraction, leading to disease progression, exercise intolerance, ventricular remodelling, arrhythmias, and premature death. The underlying mechanisms to these processes are not yet fully understood, but the current treatments influence this dysregulation, towards an inhibition of sympathetic hyperactivation. New therapies, such as the stimulation of carotid baroreceptors, enhance this inhibition to restore autonomic balance and to be able to cope with these mechanisms. CASE SUMMARY: We report the case of a 76-year-old male with advanced HF at an advanced stage, refractory to optimal treatment, and included in a programme of ambulatory infusions of Levosimendan as compassionate treatment. The patient presented with multiple episodes of decompensated HF secondary to ventricular arrhythmias. A multidisciplinary team decided to implant a baroreceptor stimulator device (Barostim Neo) in order to improve HF symptoms and quality of life, as well as trying to decrease the burden of arrhythmias. The procedure was performed with no complications and good therapeutic response, resulting in a significant reduction of arrhythmias. DISCUSSION: Treatment with a baroreceptor stimulating device is presented as a safe and effective option in our patients with advanced HF refractory to conventional treatment, to improve their quality of life and reduce symptoms; in addition to appearing as a promising option in those with arrhythmic events, which are difficult to control with usual treatments and procedures.

Quality of Life After Ministernotomy Versus Full Sternotomy Aortic Valve Replacement.

Quality of life and patient satisfaction after ministernotomy have never been compared to conventional full sternotomy in randomized trials. The QUALITY-AVR trial is a single-blind, single-center, independent, randomized clinical trial comparing ministernotomy to full sternotomy in patients with isolated severe aortic stenosis scheduled for elective aortic valve replacement. One hundred patients were randomized in a 1:1 computational fashion. The primary endpoint was a difference between intervention groups of ≥0.10 points in change from baseline quality of life Questionnaire EuroQOL-index, measured at 1, 6, or 12 months. Secondary endpoints were differences in change from other baseline EuroQOL-index utilities, cardiac surgery-specific satisfaction questionnaire (SATISCORE), a combined safety endpoint of 4 major adverse complications at 1 month (all-cause mortality, acute myocardial infarction, neurologic events, and acute renal failure), bleeding through drains within the first 24 hours, intubation time, and other minor endpoints. Clinical follow-up was scheduled at baseline, 1, 6, and 12 months after randomization. Change from baseline mean difference EQ-5D-index was +0.20 points (95% confidence interval 0.10-0.30, P < 0.001) and median difference +0.14 (95% confidence interval 0.06-0.22, P < 0.001), favoring the ministernotomy group at 1 month. Patient satisfaction was also better at 1 month (Satiscore 83 ± 9 vs 77 ± 13 points; P = 0.010). The ministernotomy group had significantly less bleeding in the first 24 hours (299 ± 140 vs 509 ± 251 mL, P = 0.001). Ministernotomy provides a faster recovery with improved quality of life and satisfaction at 1 month compared to full sternotomy.

Outcomes of Isolated Tricuspid Valve Surgery.

BACKGROUND: Isolated tricuspid valve surgery is a rarely performed procedure and traditionally is associated with a bad prognosis, although its clinical outcomes still are little known. The aim of this study was to assess the short- and long-term clinical outcomes obtained at our center after isolated tricuspid valve surgery as treatment for severe tricuspid regurgitation. METHODS: This retrospective study included 71 consecutive patients with severe tricuspid regurgitation who underwent isolated tricuspid valve surgery between December 1996 and December 2017. Perioperative and long-term mortality, tricuspid valve reoperation, and functional class were analyzed after follow up. RESULTS: Regarding surgery, 7% of patients received a De Vega annuloplasty, 14.1% an annuloplasty ring, 11.3% a mechanical prosthesis, and 67.6% a biological prosthesis. Perioperative mortality was 12.7% and no variable was shown to be predictive of this event. After a median follow up of 45.5 months, long-term mortality was 36.6%, and the multivariate analysis identified atrial fibrillation as the only predictor (Hazard Ratio 3.014, 95% confidence interval 1.06-8.566; P = 0.038). At the end of follow up, 63.6% of survivors had functional class I. CONCLUSIONS: Isolated tricuspid valve surgery was infrequent in our center. Perioperative mortality was high, as was long-term mortality. However, a high percentage of survivors were barely symptomatic after follow up.

Cirugía cardiaca mediante mínimo acceso. Registro multicéntrico español / Miniaccess heart surgery. A spanish multicenter registry

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Quality of life, satisfaction and outcomes after ministernotomy versus full sternotomy isolated aortic valve replacement (QUALITY-AVR): study protocol for a randomised controlled trial.

BACKGROUND: During the last decade, the use of ministernotomy in cardiac surgery has increased. Quality of life and patient satisfaction after ministernotomy have never been compared to conventional full sternotomy in randomised trials. The aim of the study is to determine if this minimally invasive approach improves quality of life, satisfaction and clinical morbimortality outcomes. METHODS/DESIGN: The QUALITY-AVR trial is a single-blind, single-centre, independent, and pragmatic randomised clinical trial comparing ministernotomy ("J" shaped upper hemisternotomy toward right 4th intercostal space) to full sternotomy in patients with isolated severe aortic stenosis scheduled for elective aortic valve replacement. One hundred patients will be randomised in a 1:1 computational fashion. Sample size was determined for the primary end point with alpha error of 0.05 and with power of 90% in detecting differences between intervention groups of ≥ 0.10 points in change from baseline quality of life Questionnaire EuroQOL-index (EQ-5D-5 L®), measured at 1, 6 or 12 months. Secondary endpoints are: the differences in change from other baseline EQ-5D-5 L® utilities (visual analogue scale, Health Index and Severity Index), cardiac surgery specific satisfaction questionnaire (SATISCORE®), a combined safety endpoint of four major adverse complications at 1 month (all-cause mortality, acute myocardial infarction, neurologic events and acute renal failure), bleeding through drains within the first 24 h, intubation time, postoperative hospital and intensive care unit length of stay, transfusion needs during the first 72 h and 1-year survival rates. Clinical follow up is scheduled at baseline, 1, 6, and 12 months after randomization. All clinical outcomes are recorded following the Valve Academic Research Consortium 2 criteria. DISCUSSION: The QUALITY-AVR trial aims to test the hypothesis that ministernotomy improves quality of life, satisfaction and clinical outcomes in patients referred for isolated aortic valve replacement. Statistically significant differences favouring ministernotomy could modify the surgical "gold standard" for aortic stenosis surgery, and subsequently the need to change the control group in transcatheter aortic valve implantation trials. Recruitment started on 18 March 2016. In November 2017, 75 patients were enrolled. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02726087 . Registered on 13 March 2016.

Cardiac, renal, and neurological benefits of preoperative levosimendan administration in patients with right ventricular dysfunction and pulmonary hypertension undergoing cardiac surgery: evaluation with two biomarkers neutrophil gelatinase-associated lipocalin and neuronal enolase.

PURPOSE: To evaluate if the preoperative administration of levosimendan in patients with right ventricular (RV) dysfunction, pulmonary hypertension, and high perioperative risk would improve cardiac function and would also have a protective effect on renal and neurological functions, assessed using two biomarkers neutrophil gelatinase-associated lipocalin (N-GAL) and neuronal enolase. METHODS: This is an observational study. Twenty-seven high-risk cardiac patients with RV dysfunction and pulmonary hypertension, scheduled for cardiac valve surgery, were prospectively followed after preoperative administration of levosimendan. Levosimendan was administered preoperatively on the day before surgery. All patients were considered high risk of cardiac and perioperative renal complications. Cardiac function was assessed by echocardiography, renal function by urinary N-GAL levels, and the acute kidney injury scale. Neuronal damage was assessed by neuron-specific enolase levels. RESULTS: After surgery, no significant variations were found in mean and SE levels of N-GAL (14.31 [28.34] ng/mL vs 13.41 [38.24] ng/mL), neuron-specific enolase (5.40 [0.41] ng/mL vs 4.32 [0.61] ng/mL), or mean ± SD creatinine (1.06±0.24 mg/dL vs 1.25±0.37 mg/dL at 48 hours). RV dilatation decreased from 4.23±0.7 mm to 3.45±0.6 mm and pulmonary artery pressure from 58±18 mmHg to 42±19 mmHg at 48 hours. CONCLUSION: Preoperative administration of levosimendan has shown a protective role against cardiac, renal, and neurological damage in patients with a high risk of multiple organ dysfunctions undergoing cardiac surgery.

Left atrial myxoma: extraction by robotic and vacuum assistance.

We report a single case of left atrial giant myxoma excision using the da Vinci S surgical system in a 47-year-old woman. A vacuum extractor device was designed to avoid tumor fragmentation or embolization. The myxoma was entirely removed under aspiration through the extractor device, achieving all the surgical tenets of myxoma excision.